Participant Information and Parent Waiver

If you have not done so already please fill out this waiver before attending your first Blooming Girls Workshop. Girls will not be allowed to stay for our workshop if we do not have a current waiver on hand. If you have any questions please contact us.

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Child's Name *

First

Last

Age *

Child's Birth Date *

Grade *

School *

Parent's Name *

First

Last

Phone Number *

Email *

Street Address *

City *

State *

Zip Code *

Child's Parent's you

Emergency Contact *

Emergency Contact Phone *

Insurance Company *

Doctor Name and Number *

List of Allergies *

List any allergies or medical issues if which the instructor should be aware.

Any Other Helpful Information *

List any information that would be helpful in understanding your child.

How did you hear about Blooming Girls Workshops? *

• Flyer
• Email
• Past Participant
• Friend
• Website
• School
• Newsletter
• Other

Which sessions do you plan on attending? *

• September
• October
• November
• December
• January
• February
• March
• April
• May

Comments or Questions

Signup for Newsletters

• I would like to receive email updates regarding future workshops

Consent *

• As the parent or Legal Guardian, I give consent for my daughter to participate in the (“Program”) offered by Blooming Girls.

1) I acknowledge that photographs will be taken during the session and agree to them being used in print and online (i.e. websites, Facebook, Instagram). If I do not agree I will advise facilitators. 2) I understand that the facilitators will not discuss what is said in the circle to anyone beyond the circle. The exceptions to confidentiality apply, which are: if the facilitator believes that a participant is at immediate risk of harming herself or someone else, and/or if a minor is a victim of physical or sexual abuse or neglect, or is a witness to a domestic violence or elder abuse. In these instances, the facilitator will need to follow the legal and ethical steps to assure safety to the participants.

Release of Carrie Sheffield and Blooming Girls from Liability *

• I have read the Release and understand all of its terms. I execute it voluntarily and with full knowledge of its significance and binding legal effect.

Submit

*Release of Carrie Sheffield and Blooming Girls from Liability                                       

In consideration of the permission granted by Carrie Sheffield and Blooming Girls(“Carrie Sheffield/Blooming Girls”) to enroll and participate in the Program, I do hereby release Carrie Sheffield/Blooming Girls and the employees, assigns, agents, heirs and members of the aforementioned, form all actions, causes of actions, damages, claims, or demands which I, my heirs, executors, administrators, or assigns may have against any and all aforementioned for any and all personal injuries, known or unknown, which I have or may incur by participation in the Program and for all damage to my property.

I realize that there are inherent dangers and risks involved in the Program and I hereby agree to hold Carrie Sheffield/Blooming Girls and the employees, assigns, agents, heirs and members of the aforementioned harmless form any loss, liability, damage or cost that they may incur due to my enrollment or participation in the Program.

I hereby agree to abide by any policies, rules and regulations adopted by Carrie Sheffield/Blooming Girls and understand that the violation of said policies, rules and regulations may result in immediate dismissal from the program without refund.

I expressly agree that this release is intended to be as broad and inclusive as is permitted by the law of Colorado and that if any portion thereof is help invalid, it is agreed that the balance shall, not withstanding, continue in full legal force and effect.  I further agree that should any dispute arise in connection with the Program that said dispute will be adjudicated in a court of competent jurisdiction in Larimer County Colorado.